Development and Evaluation of Electronic Medical Record Admission Module in Intensive Care Unit: A Case Study in Iran

Document Type : Original Article


1 MSc in Health Information Technology, Student Research Committee, School of Health Management and Information Sciences, Health Human Resources Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

2 Department of Health Information Management, School of Health Management and Information Sciences, Health Human Resources Research Center, Clinical Education Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

3 Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

4 Department of English, Shiraz University of Medical Sciences, Shiraz, Iran

5 Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

6 Department of Health Information Management, School of Health Management and Information Sciences, Health Human Resources Research Center, Shiraz University of Medical Sciences, Shiraz, Iran


Introduction: Electronic medical record leads to effective information management. One of
the most important sections of electronic medical records is the patient admission module.
The aim of this study was to develop and evaluate the patient admission module in Intensive
Care Unit.
Methods: This developmental-applied study was conducted in 2021 in 3 steps: 1. Determining
the requirements, 2. Designing, developing, and implementing, and 3. Evaluating usability.
In the first step, we did the literature review and asked for the expert panel’s opinion; in the
second step, we used word, and Reactjs, Expressjs programming language, and Mongodb
database and Windows server; in the third step, the USE standard questionnaire was used.
Results: Module requirements were classified into two categories: functional and nonfunctional
requirements. Functional requirements address software quality features, and nonfunctional
requirements include general requirements, demographic information, and clinical
information. Demographic information was classified into two main categories: patient’s
demographic information and documented physician information. Clinical information (287
data elements) in 13 main categories included the past history, vital signs, nervous system,
respiratory system, cardiovascular system, genitourinary system, gastrointestinal system,
hematology, integumentary system, infectious, antimicrobial drugs, problem list, and plan.
Also, the results of usability evaluation showed that 87% of the physicians agreed with the
use of this module.
Conclusion: Given the trend towards e-health in Iran, the use of electronic medical record
admission module in intensive care units can have a significant impact on the complete
collection of admission data.


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